Where Margaret found hope
Repeated emergency visits and hospitalizations are common among patients like Margaret Taylor, who have chronic medical problems and a lack of resources. Health care providers at UF Health’s Care One Clinic work with these patients to find solutions. So far, the results are convincing.
By Laura Mize
Chronic illness has become the story of Margaret Taylor’s life. Abdominal angioedema, non-alcoholic liver cirrhosis, chronic obstructive pulmonary disease and her most serious diagnosis — cancer of the lung, throat and brain — consume much of her time and prevent her from getting a job.
“I’m only 45,” Taylor laments. “My children are grown, except for my youngest is 17. I’ve got four grandbabies. This is not how I planned my life out, you know, to have these diseases and have cancer.”
The Lake County woman began her second round of chemotherapy at UF Health Shands Hospital in early April. She lived off and on at the American Cancer Society Winn-Dixie Hope Lodge in Gainesville from December through mid-March while undergoing her first cycle of treatment, but now must travel between the hospital and her home because her treatments will be less frequent. Taylor scrapes by on financial support from her 77-year-old mother and a small amount of money brought in through a fundraising website her children started on her behalf.
Taylor last had a job and health insurance in 2010 when she worked as a manager for Jackson Hewitt Tax Service in Mississippi. She left that position to return to Florida and soon became ill. Since then, she has cycled through a local clinic and the emergency departments at a few different hospitals.
“I was going to my local hospitals and they were just shooting me up with drugs and sending me home, telling me that they didn’t know what the problem was,” she explains. “From Lake County, I came to (the UF Health) Shands emergency room and went in and they immediately admitted me.”
After several days at UF Health Shands Hospital in the late spring of 2013, Taylor was released and advised to follow up with her general practitioner.
“I told them, ‘I don’t have a primary care physician,’” Taylor says.
Getting to the root of the problem
For patients such as Taylor who lack health coverage, E.R. visits are often the only recourse for getting health care. But these revolving-door visits to emergency departments do little to improve the overall health of patients.
“When patients need chronic medical care, including treatment of mental illness and addiction, the E.R. is not the appropriate venue,” said Deepa Borde, M.D., medical director of UF Health’s Care One Clinic. The clinic serves as a safety net for UF Health patients who, like Taylor, lack a primary care doctor or have been to the UF Health Shands Hospital E.R. more than eight times in a 12-month period.
“The E.R. physician’s primary focus is on the medical stabilization of emergency conditions and the appropriate disposition of patients: either discharge home or admission to the hospital,” Borde continued.
Lack of transportation to reach a primary care physician and the desire for prompt medical attention are some of the reasons patients visit emergency rooms even when there is not an emergency, she said.
Despite Taylor’s numerous visits since 2010 to several different hospitals, her cancer went undetected until UF Health doctors found it in 2013. By that point, it already had taken root in three areas of her body. Along the way, one doctor diagnosed her with congestive heart failure. The UF Health doctors seeing her now believe that diagnosis was erroneous and say she does not currently have the disease. Without congestive heart failure, Taylor is one step closer to qualifying for a procedure that could significantly improve her health: a liver transplant. Her cancer still stands in the way.
Borde is working to help Taylor address her health hurdles one by one. The Care One Clinic, in operation since November 2012, is funded by a two-year grant from the state of Florida, worth about $660,000.
“The patients that we take care of are what the Agency for Healthcare Research and Quality defines as vulnerable patients,” says Borde, an assistant professor in the UF College of Medicine’s department of medicine. “These are patients who are vulnerable because of their age or financial circumstances, their place of residence or their multiple medical problems. They are medically frail patients.”
In addition to numerous health conditions, Care One patients face “many barriers to health care,” Borde says. Lack of transportation, housing, health insurance, dental care and money to purchase medications are common challenges for people the clinic serves. That’s where Care One’s team approach and lengthy time slots for patient visits come in handy.
A social worker, a pharmacist and a nurse work alongside Borde and three other primary care physicians: Robert Leverence, M.D., a professor in the department of medicine, and Sharon Gavin, M.D., and Susan Nayfield, M.D., both associate professors in the same department. Leverence started the clinic, modeling it after one by the same name, which he founded, at the University of New Mexico. Borde, Leverence and Gavin all are hospitalists experienced in working in hospital settings with the kind of patients Care One serves. Robert Rout, M.D., works in the clinic two half-days each week, offering pain management and other services.
Together, the providers brainstorm how to help each patient overcome his or her own unique challenges. The team coordinates specialist care for patients, such as Taylor’s oncology appointments and a recent cardiology checkup to re-evaluate her heart health. The clinic is open several half-days a week and the doctors see, on average, four to five patients each day, allowing time for extensive discussions with each one. People enrolled in the UF Health Shands Charity Care program, which waives charges for approved patients who cannot afford to pay for their care, also receive free services at Care One. Other patients are charged for the services they receive or, for some, their insurance is billed.
Care One’s social worker connects patients with resources and programs in the community or through other UF Health entities to help them with some of their non-medical problems.
“By addressing some issues that are not necessarily considered medical, you help that person as a whole so that we can keep them out of the hospital and keep them from coming to the E.R.,” says Jacqui Pinkney, M.S.W., the clinic’s social worker.
In addition to the medical care she receives, Taylor says Care One has connected her with a dental clinic to fix a broken tooth and resources to help her pay for gas and medications. She says Pinkney and Borde both have been there to listen when she was upset, and she credits the team for saving her life by finding her cancer.
Taylor’s application for disability benefits was recently approved, and she is awaiting enrollment in Medicare. With that in place, she eventually will have to move on from Care One to find another physician. The clinic is not meant to be a permanent solution for patients.
“Then Dr. Borde, I’m sure, will refer me to someone good, but I’m going to fight to stay with Care One,” Taylor says. “If it can be done, I’m going to do it.”
The bottom line
Records show the Care One Clinic has significantly reduced some patients’ E.R. visits and admissions at UF Health Shands Hospital. Overall, Care One patients visit the Shands E.R. 25 percent less in the six months after their first visit to the clinic than they did in the six months beforehand. In the same period, they also have a 27 percent reduction in hospitalizations and a 32 percent decline in the number of days spent in the hospital.
These numbers show the clinic is succeeding at its primary and secondary missions.
“Our primary goal is to keep patients healthy and improve their quality of care,” Borde says. “That’s always in our forefront. But yes, certainly on a more practical level, the cost savings are important.”
Reducing admissions and emergency visits by patients who typically cannot pay for their care saves UF Health money by sparing resources and personnel time. Doing so also helps the system work toward a big-picture goal: avoiding penalties levied against hospitals whose readmission rates for certain patients exceed federal standards.
The Affordable Care Act prescribes acceptable rates of re-hospitalization for Medicare patients with certain common ailments. Nationwide, hospitals forfeited $227 million in Medicare reimbursements in 2013 for too many readmissions among patients with pneumonia, heart attack and heart failure, according to Kaiser Health News reports. In 2012, the first year of the penalties, that amount exceeded $280 million. Some hospitals manage to avoid penalties in a given year, but that will become increasingly difficult. The list of health conditions considered in the calculations will grow, while future penalties will cut reimbursements at higher percentages.
Borde does not yet have figures on how much the Care One Clinic has saved the UF Health system. And, while she acknowledges the importance of conserving resources, the positive impact on patients is what satisfies her most.
“Working in this clinic, by far, has been one of the most rewarding things I’ve done in my career,” she says. “I feel like every day I see at least two to three patients who I know that we’ve helped, not that we’re doing any rocket science here. It’s simply that we’ve been able to take the time to listen and delve deep and find out the root cause of what’s been going on.”